Cholera remains a major public health concern in Ethiopia, particularly in conflict-affected agro-pastoral regions where access to healthcare, clean water and vaccination is limited. The main objective was to identify predictors of time to recovery from cholera among patients in a conflict-affected agro-pastoral area of Ethiopia using survival analysis models. Understanding the clinical and epidemiological factors influencing recovery time is critical for improving outcomes and guiding outbreak responses. A retrospective cohort study was conducted using data from cholera treatment centers in a conflict-affected agro-pastoral region. Time to recovery was analyzed using Kaplan-Meier recovery curves, Cox proportional hazards, and Accelerated Failure Time (AFT) models. Variables included clinical signs, demographic factors, vaccination status, and exposure history. Severe dehydration (HR = 0.49, p < 0.0001; TR = 1.49), low pulse rate (HR = 0.69, p = 0.005), and lack of vaccination (HR = 0.56, p < 0.0001) were associated with significantly longer recovery times. Notably, patients with known contact with cholera cases showed slower improvement (HR = 0.63, p = 0.0003), suggesting higher exposure or delayed care-seeking. Vaccinated individuals and those with mild dehydration recovered significantly faster. The log-Normal AFT model confirmed these findings, showing prolonged recovery among high-risk groups. In conflict-affected agro-pastoral settings, clinical severity, vaccination status, and exposure history are key determinants of cholera recovery time. These findings underscore the importance of early case detection, aggressive rehydration, and targeted vaccination, especially among known contacts and high-risk individuals. Public health interventions should prioritize rapid response strategies and contact-based follow-up to reduce disease burden and improve recovery outcomes.

Shelter and settlement are critical determinants of health in humanitarian crises, yet their impacts on health outcomes remain underexplored. This review synthesizes published evidence on how shelter and settlement interventions impact health outcomes in humanitarian crises. A systematic review of peer-reviewed literature was conducted to identify studies examining the association between shelter and settlement interventions and health outcomes in humanitarian crises. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines a protocol was developed and three databases were searched for studies published between 2005 and 2025. Relevant data were extracted and thematically analysed. A total of 138 articles were found. Thematic analysis identified six themes (living conditions, accommodation type, camp and site planning, displacement status, essential household items and cash-based interventions). Three cross cutting themes of gender, climate change and vulnerability were also identified. Two themes (living conditions and accommodation type) are presented here. Poor living conditions including damaged shelters, poor housing design and materials were associated with increased risks of communicable diseases such as malaria, diarrhoea, and soil-transmitted helminth infections while overcrowding heightened injury risk and psychological distress. Accommodation type influenced health outcomes with short-term shelters linked to acute mental health challenges and increased injuries; medium-term shelters with increased risk of non-communicable disease; and long-term housing with deteriorations in chronic disease management. This systematic review synthesises the evidence base showing how shelter and settlement interventions play a role in influencing health outcomes in humanitarian crises. It shows that shelter is a critical yet often under recognised determinant of health in these settings. Health outcomes are influenced by housing quality, accommodation type and duration, camp and settlement planning, displacement dynamics including frequency and length of displacement, and access to essential household items. Poor shelter conditions are likely to increase the risk of communicable diseases and mental health issues and have the potential to worsen chronic disease outcomes and risk. A key contribution of this review is the identification of shelter as a core entry point for public health action, highlighting the need for clearer operational guidance on shelter typologies, minimum standards, and their integration with health, protection and social services.

Access to essential medicines is a fundamental human right and a critical pillar of effective healthcare. In Africa, armed conflicts severely weaken health systems, disrupting the availability of essential medicine, leading to gaps in patients' treatment and, in turn, posing a serious risk to overall public health. Therefore, this study aimed to identify the impact of armed conflicts on the availability of essential medicines as a cornerstone of healthcare across African regions, and quantify the extent of this disruption over time and by country. In this systematic review and meta-analysis, data were retrieved from published articles accessible in PubMed, Semantic Scholar, and grey literature covering the period from 1985 to 2025 and 2001 to 2024 for system impact and medicines availability studies, respectively. The literature search was conducted from January to May 2025. Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, studies were independently screened by two reviewers and included if they contained information on medicine availability or its relation to health systems in conflict zones and were published in English. The quality of studies was evaluated using the Joanna Briggs Institute criteria. Pooled estimates of medicine availability and their 95% CIs were obtained using a random-effects analysis. Heterogeneity was assessed using the I² statistic. The risk of bias and small study effects were assessed with funnel plots and Egger's test. Additionally, the leave-one-out sensitivity test and influence diagnostics test were considered to evaluate study-level impact. The review included data from 1,581 health facilities and 989 essential medicines across eight conflict-affected African countries. The pooled availability of essential medicines calculated from the data obtained from 41 studies conducted in African countries shouldering frequent armed conflict was estimated at 55% (95% CI, 47-63), with substantial heterogeneity across studies (I² = 93%, p < 0.001). Country-level analysis showed the highest availability in the Central African Republic (79%; 95% CI, 49-95) and the lowest in Nigeria (40%; 95% CI, 1-78). A temporal decline in medicine availability was observed, from 76% (2001-2010) to 46% post-2020. No significant publication bias was detected (funnel plot asymmetry p = 0.9560; Egger's test p = 0.494). Additionally, the influence diagnostic test and the leave-one-out sensitivity analysis indicated that observed heterogeneity likely reflects methodological differences and the sample size across the studies rather than bias or outliers. The systematic review revealed that armed conflicts have profoundly compromised health system functionality through the destruction of healthcare infrastructure, closure of medical facilities, displacement of the health workforce, pervasive insecurity and psychological distress among healthcare providers, and disruptions in supply chains and transportation networks, all of which have adversely affected the accessibility of essential medicines. On average, only 55% of essential medicines were available in conflict-affected regions of Africa, which was below the WHO benchmark of 80%. This finding underscores the severe threat that armed conflict poses to medicine availability and, consequently, to increased indirect morbidity and mortality. Additionally, the conflict undermines medicine availability through multiple, often interconnected mechanisms, indicating the need for a coordinated, multisectoral approach to ensure continuous access to essential medicines. Therefore, strengthening healthcare infrastructure in conflict settings is critical. Furthermore, the international community should enforce accountability mechanisms for violations affecting healthcare services, while donors and regional humanitarian assistance and emergency response mechanisms should increase investment and medicine supply in resilient medicine supply systems capable of maintaining availability during periods of armed conflict. The study protocol was registered in PROSPERO (CRD420251154811), the International Prospective Register of Systematic Reviews, maintained by the National Institute for Health and Care Research (NIHR).

Armed conflicts severely disrupt cancer care delivery, destroying infrastructure and limiting access to essential diagnostics and treatments. Evidence on service challenges, adaptations, and policy implications remains fragmented. This scoping review of four databases (Scopus, PubMed, ScienceDirect, and CINAHL) was conducted for original peer-reviewed studies published between January 2020 and August 2025. The search focused on the effect of wars on cancer service delivery in conflict zones, and its impact on cancer care. Wars in conflict-affected countries like Palestine, Sudan, Syria, Iraq, Ukraine, and Afghanistan caused widespread destruction of cancer infrastructure, unsafe hospitals, and interruptions in chemotherapy, radiotherapy, and surgery. Countries faced shortages of specialized centers, technicians/radiologists, and medical records, alongside high costs and supply chain disruptions. Despite these challenges, healthcare systems demonstrated resilience through adaptations including Ukraine's MedEvac program for EU treatment evacuation, cross-border referrals (Iraq→Lebanon, Afghanistan→Pakistan), telemedicine, mobile diagnostic units, and community-based care models. Policy responses emphasized international aid coordination, conflict-sensitive health planning, and supply chain restoration. Conflicts cause infrastructure destruction, workforce depletion/migration, treatment barriers/delays, drug supply disruptions, and psychosocial/economic impacts, which in turn create urgent policy/governance challenges. Although humanitarian aid may provide temporary relief, sustainable solutions require peace and global commitment, grounded in equity and the fundamental right to health.

Adolescence is a critical developmental stage marked by physical, psychological, and cognitive growth, increasing autonomy, social exploration, and risk-taking behaviors. However, these natural transitions in displacement settings are overshadowed by heightened vulnerabilities such as gender-based violence. In many displacement settings, recurrent exposure to violence leads to its acceptance as an unavoidable part of daily life. Sometimes, violence is normalized, leading to further exacerbation of the crisis. Our study explored the in-depth experiences and normalization of abuse and existing barriers to reporting within the internally displaced persons settlement in Cross River State, Nigeria. Our qualitative study included adolescents and young people aged 15-24 years residing in the Bakassi Internally Displaced Persons camp within the Bakassi Local Government Area. Participants were selected via purposive sampling. Data were collected through 12 individual interviews and 3 focus group discussions. Data were transcribed verbatim, and thematic analysis was conducted using NVivo 14 to identify key themes. Findings from the study reveal participants' experiences with sexual exploitation, abuse, harassment, and gender-based violence, as well as their perceptions of abuse and how it is normalized. Contextual factors such as self-blame, societal pressure to accept advances from men, and limited accountability contribute to heightened vulnerability within the camps, which result in emotional and psychological impacts. Barriers to reporting and seeking help included fear of repercussions, lack of trust in authorities or services, and stigma associated with victimhood. Our study demonstrates that normalization of abuse, alongside systemic barriers such as fear of repercussions, stigma, and limited trust in authorities, significantly constrains reporting and help-seeking behaviors. Furthermore, our study identifies weak and largely absent accountability mechanisms as a key structural factor enabling continued abuse. To enhance accountability and safeguard vulnerable populations, appropriate legal penalties and enforcement measures should be applied to all forms of abuse. Additionally, future interventions should also address the underlying vulnerabilities that predispose individuals to abuse, ensuring a more comprehensive approach to prevention and protection.

International humanitarian organizations providing surgical care in conflict-affected settings have an ethical obligation to adopt practices that promote sustainable surgical services. Our objective was to evaluate the prevalence of sustainable surgical practices and policies implemented by humanitarian organizations in conflict-afflicted settings, as well as to document instances where surgical services were disrupted or discontinued due to the outbreak of conflict. A review of primary literature was conducted using Medline. Articles were included if they described sustainable surgical practices or policies in conflict-affected settings. Sustainability was defined according to a previously published modified Delphi consensus framework, which outlined key pillars of sustainability in global surgery partnerships. A grey literature review was also performed to identify sustainable policies published by international humanitarian organizations on their online platforms. Of 1,057 articles screened, 29 articles met inclusion criteria, describing 54 surgical programs implemented by 17 international humanitarian organizations -most commonly Médecins Sans Frontières (n = 27) and International Committee of the Red Cross (n = 5). These programs were implemented in 36 conflicts between 1946 and 2023, most commonly in Sub-Saharan Africa (n = 20), the Middle East (n = 11), and Southeast Asia (n = 9). The following six sustainability pillars were explicitly described: context-relevant education (94.4%), multidisciplinary involvement (74.1%), outcome measurement (72.2%), stakeholder engagement (66.7%), handover to local stakeholders (18.5%), and multisource funding (13.0%). Escalating violence led to permanent closure of 13.0% of programs and led to service interruptions in 9.3%. The mean duration of programs was 9.5 ± 9.7 years. Publicly available policies were identified for six organizations (35.3%), and all but one organization captured every aforementioned pillar of sustainability. International humanitarian organizations have increasingly adopted sustainable practices and policies when delivering surgical care in conflict-affected settings-most notably in the area of context-relevant training. We encourage global actors to continue prioritizing this domain, especially in fragile states where service cessation or interruptions can occur at any time, necessitating sustainable surgical care delivered by trained local physicians. This review highlights exemplary practices documented in the literature and offers insights into how global surgery partners can build on existing efforts.

Anemia remains a significant public health issue, especially in emergency areas and refugee camps. This study was conducted to determine the prevalence of anemia and its associated factors among children aged 6 to 59 months in Qoloji internally displaced people camp site, Somali Region, eastern Ethiopia. A community-based cross-sectional study was conducted among 401 children aged 6 to 59 months. Capillary blood was collected and hemoglobin level was determined using HemoCue Hb 301. Data was analyzed using SPSS version 26. Bivariable and multivariable logistic regression were used to identify determinants of anemia. The overall prevalence of anemia was found to be 51.4% (95% CI: 46.6%, 56.4%). Of the anemic children 29.4% (95% CI: 25.2%, 33.9%), 16.7% (95% CI: 13.2%, 20.7%) and 5.2% (95%CI: 3.2%, 7.5%) had mild, moderate, and severe anemia respectively. Initiation of complementary feeding below 6 months (AOR = 2.6;95% CI:1.5,4.6), household food insecurity (AOR = 5.4;95% CI:2.8,10.2), mothers of child having no formal education (AOR = 2.8; 95% CI: 1.3, 5.7), inadequate dietary diversity (AOR = 7.9; 95%CI:4.4, 13.9) and lack of antenatal care follow up during pregnancy (AOR = 3.5;95% CI:1.8, 6.7) were found associated with of anemia. The prevalence of anemia was high among children. Household food insecurity, dietary diversity, initiation of complementary feeding, maternal educational status and antenatal care during pregnancy were factors found associated with anemia. Therefore, adequate interventions should be designed and implemented considering improvement of household food security, access to maternal education and dissemination of nutrition and health related information.

High infant mortality rate (IMR) is a critical public health indicator. Understanding its trajectory is vital for policymaking, particularly in Somalia, where rates remain elevated. This study aimed to model and forecast Somalia's IMR to identify the most accurate method, providing data-driven insights for public health strategy. The study aimed to formulate time series models, propose hybrid models, and rigorously compare their performance in forecasting IMR. This quantitative time-series analysis utilized annual World Bank data for Somalia from 1950 to 2022. Three models were developed: Autoregressive Integrated Moving Average (ARIMA), Artificial Neural Network (ANN), and a hybrid ARIMA-ANN model. Performance was evaluated using Root Mean Square Error (RMSE) and Symmetric Mean Absolute Percentage Error (sMAPE) on a test set spanning 2013 to 2022. Upon achieving stationarity via first-order differencing, the ARIMA (1, 1, 3) model proved most effective. It demonstrated superior accuracy with an RMSE of 0.85, significantly outperforming the ANN (RMSE 1.04) and hybrid models (RMSE 3.01). Validated ARIMA forecasts project a continued, gradual decline in IMR from 59.02 deaths per 1,000 live births in 2023 to 40.37 in 2032. The ARIMA model offers the most reliable framework for forecasting Somalia's infant mortality rate based on historical data.

Patients receiving maintenance hemodialysis are highly vulnerable during armed conflict, particularly when healthcare systems are disrupted. However, factors associated with survival under prolonged disruption remain poorly understood. This study examined survival and key associated factors among hemodialysis patients during the armed conflict in Sudan. We conducted a retrospective cohort study of 158 adults receiving maintenance hemodialysis in Khartoum, Sudan, at the onset of the April 2023 conflict, with follow-up extending up to 18 months. Outcomes were confirmed for 122 patients, while 36 were untraceable and censored at their last verified contact. Participants were categorized according to displacement trajectory within the first three months. The primary outcome was survival. Key variables included displacement trajectory, dialysis frequency during follow-up, and out-of-pocket costs. Risk ratios and time-to-event approaches were used to examine associations, with sensitivity analyses conducted to assess the impact of loss to follow-up. Of the 122 patients with confirmed outcomes, 53.3% remained alive at the end of follow-up. Survival rates differed across displacement trajectories: 81.8% among those who relocated internationally early, 53.3% among those who achieved internal settlement, 34.6% among those who experienced secondary displacement, and 13.8% among those who remained in the capital. Higher survival was observed among patients receiving at least two dialysis sessions per week compared with those receiving one or fewer sessions or emergency-only dialysis (68.8% vs. 43.2%; RR 1.59, 95% CI 1.15-2.20). Financial burden was substantial, with monthly dialysis-related costs ranging from USD 720-3,600 during early displacement and remaining high thereafter (USD 500-3,500). Survival differed across displacement patterns and dialysis continuity, and was influenced by financial burden. These findings underscore the need for conflict-adapted dialysis strategies and improved financial protection for patients reliant on life-sustaining therapies.

The full-scale invasion of Ukraine has generated the largest refugee crisis in Europe since the Second World War, exposing civilians to trauma, displacement, and prolonged uncertainty. Refugees face stressors across multiple ecological levels, making Bronfenbrenner's model a suitable framework for understanding mental health determinants. This study examined multilevel predictors of psychological distress among Ukrainian war refugees in Europe. A cross-sectional study was conducted in 2025 across eight European countries. A total of 1,622 adult refugees completed standardized questionnaires. Psychological distress was assessed with the Refugee Health Screener-15 (RHS-15), and cultural trauma symptoms with the Cultural Symptoms of Trauma Scale (CSTS). Sociodemographic, relational, economic, institutional, cultural, and temporal variables were organised within Bronfenbrenner's ecological model. Group comparisons were conducted using non-parametric tests, and predictors of distress were identified through logistic regression. Higher distress was associated with poorer self-rated health, weaker family and social relationships, unemployment, economic strain, and contact with family in war-affected areas. The strongest predictors were macrosystem factors, including emotional, cognitive, existential, and agency-related trauma symptoms (OR 1.40-2.78). Protective factors included better health, stronger family relationships, employment, and favourable economic conditions. Refugees who left Ukraine later in the conflict showed lower distress risk. Mental health outcomes among Ukrainian refugees reflect interactions across ecological levels. Interventions should integrate individual, relational, community, economic, and culturally informed components to address the multifaceted nature of refugee distress.